Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that includes all of the required content required by regulation.
The findings included:
Nine client records requiring informed and voluntary consent to release information forms were reviewed on July 16, 2014. The facility failed to document the purpose of disclosure on informed and voluntary consent to release information forms in client records 1, 3, 4 and 9.
Client #1 was admitted to the outpatient facility on 5/28/14. Client #1's informed and voluntary consent to release information to the client's primary care physician dated 5/28/14 identified the purpose of disclosure as "PCP".
Client #3 was admitted to the outpatient facility on 4/30/14. Client #3's informed and voluntary consent to release information to the client's primary care physician dated 4/15/14 did not specify the purpose of disclosure.
Client #4 was admitted to the outpatient facility on 1/23/14. Client #4's informed and voluntary consent to release information to the client's primary care physician and probation officer both dated 1/6/14 did not specify the purpose of disclosure. The client's informed and voluntary consent to release information to the client's primary care physician dated 1/23/14 indicated the purpose of disclosure as "PCP".
Client #9 was admitted to the outpatient facility on 5/21/14. Client #9's informed and voluntary consent to release information to the client's primary care physician dated 5/21/14 identified the purpose of disclosure as "PCP".
The outpatient supervisor confirmed the findings.
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Plan of Correction
The Executive Director and the Assistant Director will conduct a staff-wide training on confidentiality and how to complete a 5 point release prior to 9/30/14. Each supervisor will conduct 3 chart audits per month per counselor/nurse to ensure releases are completed in an appropriate manner. Client charts 1, 3, 4, and 9 will be fixed in the following manner:
Client 1 was discharged on 6/26/14.
Client 3 was discharged on 7/1/14.
Client 4 will have new releases completed and in the chart by 8/29/14.
Client 9 will have new releases completed and in the chart by 8/26/14. |